The complex world of caring for your ill parent means practicing love, acceptance, and sometimes even yelling at God.

By Virginia Stem Owens

I had never seen the logic in asking "Why me?" when some calamity befell me. Couldn't one just as reasonably ask "Why not me?" But when my mother began to show signs of dementia from Alzheimer's disease, I found myself asking on her behalf, "Why her?" If ever a person did not deserve such a fate, it was my mother. She was a good, generous, funny, loving person who had already suffered a number of tribulations in her life.

But deserving has little to do with disease. Like the rain, it falls on the just and the unjust. And, as suddenly as a summer thunderstorm, my mother's care fell to me as she declined into dementia and finally to death over a seven-year period. In this country, millions of people are living through similar experiences. Knowing my own desperation while I tried to help both my parents during those years, I've gathered some expectations, suggestions, and nuggets of wisdom that might help others.

This month Bill Gates starts his new full-time career as a humanitarian, leaving behind the software bugs to swat the kind that cause malaria.

We often think of those trying to save the world as bright-eyed young people, but Mr. Gates is part of a booming trend: the “encore career” as a substitute for retirement. Definitions are still in flux, but an encore career typically aims to provide a dose of personal satisfaction by “giving back.”

Some 78 million American baby boomers are now beginning to retire, and one survey this year by a research institute found that half of boomers are interested in starting such new careers with a positive social impact. If we boomers decide to use our retirement to change the world, rather than our golf game, our dodderdom will have consequences for society every bit as profound as our youth did.

One example of this trend is Peter Agre, a medical doctor who won the Nobel Prize for Chemistry in 2003 for research on ... on ... well, on something to do with cell membranes that I still don’t understand. Dr. Agre could have run his lab indefinitely but was restless to assume a challenge that would more directly affect society.

He thought about politics, but ended up taking on a fancy administrative position at Duke University, thinking he could help shape students and education. Then he became restless again, and this year he took a substantial pay cut to head the Malaria Research Institute at Johns Hopkins University.

“It wasn’t a matter of being a Mother Teresa,” Dr. Agre said. “It was a matter of, ‘Boy, that sounds like fun!’ ”

Yet he concedes — a little bashfully — that there is also a thrill at the possibility of helping overcome malaria, one of the great scourges of humanity. These days, Dr. Agre presides over a team of 20 scientists working on everything from designing malaria vaccines to engineering a malaria-resistant mosquito that in theory could outcompete others if released in the wild.

Marc Freedman, author of a book called “Encore: Finding Work that Matters in the Second Half of Life,” notes that adolescence is a relatively modern concept; until the 19th century teenagers normally were treated as adults. In the same way, he says, a new life stage is emerging — the period of 10, 20 or even 30 years after one’s main career is completed but before infirmity sets in.

The best things that graying do-gooders bring to philanthropy is their management experience and Rolodexes. Bill and Melinda Gates are most noted for showering billions of dollars on public health, but perhaps just as important has been the hard-nosed business sensibility they invoke, demanding metrics to demonstrate that particular approaches are cost-effective.

Aside from Mr. Gates and Dr. Agre, another general in the war on malaria is Rob Mather, a British management consultant who — thank heaven! — isn’t very handy with a TV remote. Mr. Mather was trying to turn off his set in June 2003 when he accidentally flipped to another channel and was riveted by the image of a 5-year-old girl who was struggling to overcome severe burns all over her body.

Mr. Mather suggested to several friends that they swim as a fund-raiser for the girl. Because Mr. Mather is relentless, the swim ended up involving 10,000 people in 73 countries and raised hundreds of thousands of dollars.

Bowled over by the possibilities of mobilizing people for good causes, Mr. Mather set up a swim the next year to raise money against malaria — and this time 250,000 participated. He left the business world and founded a group called Against Malaria, now one of the world’s leading organizations battling the disease.

Mr. Mather browbeats businesses into donating services and covering overhead — “we have 17 legal firms working for us, and we’ve never paid a legal bill” — so every dollar donated to the organization ends up actually used to buy bed nets for families that can’t afford them.

He said he had just received e-mail about an African village that had 387 cases of malaria per month before the bed nets were distributed and seven cases per month afterward. Mr. Mather’s work has resulted in hundreds of thousands of bed nets being shipped abroad to save lives so far — all of which he finds rather more fulfilling than his previous, more lucrative career.

If more people take on encore careers like that, the boomers who arrived on the scene by igniting a sexual revolution could leave by staging a give-back revolution. Boomers just may be remembered more for what they did in their 60s than for what they did in the Sixties.

As any amateur futurologist can tell you, the rich world is rapidly getting older. By 2050, more than a quarter of the developed world's population will be over 65.

At the moment, that group makes up about a sixth of the rich-world population, and only about 25 per cent of them are over 80. In 2050, the octogenarians and their elders will comprise 40 per cent of the 65-plus cohort in wealthy countries.

This greying of the prosperous parts of the world has long been foreseen, if not very well prepared for. Much less well known is the fact that well-off countries are far from alone in facing the prospect of an aging population.

Babies born today in poorish countries such as Thailand or Jamaica can reasonably expect to live into their 70s. And as more and more Indians and Chinese escape from poverty, they too will have much longer spans.

By 2050, the percentage of the Indian population over 80 will have risen fivefold, and the same segment in China will have gone up six times.

Such changes happen for two reasons: people's general health is better, meaning they wear out later, and preventable deaths of the relatively young are, in fact, prevented. As anti-retroviral treatment for HIV-AIDS becomes more common, childbirth safer and malaria more treatable, people will die at a more advanced age.

By 2050, close to 80 per cent of all deaths in the world are expected to occur in people who are older than 60.

While people 59 or under die in any number of dramatic ways, people on the other side of 60 face three possibilities which between them carry off most of the elderly, whatever their economic circumstances. Each peaks in a different decade, and each produces a different sort of end of life.

The first is cancer: most victims function reasonably well before entering a steep decline. Cancer deaths peak at 65-plus, and more and more sufferers recover. If they do, two other clouds appear on the horizon. One of these is chronic organ failure and the other is frailty, dementia and decline.

Chronic problems with an organ -- usually heart disease or emphysema -- bring a gradual decline punctuated by severe episodes, such as a heart attack or lung failure.

Dementia or frailty can mean a long, poor-quality end of life. As more cures are found for cancer, and sensible types give up smoking and bacon, more people will find that a slow decline is the meagre reward for their virtuous behaviour. That applies to developing countries as well as rich ones.

There has never been a bigger need for cheap, effective treatment for diseases of the old, such as Alzheimer's, or for easier access to pain relief and reliable care.

The influenza vaccine, which has been strongly recommended for people over 65 for more than four decades, is losing its reputation as an effective way to ward off the virus in the elderly.

A growing number of immunologists and epidemiologists say the vaccine probably does not work very well for people over 70, the group that accounts for three-fourths of all flu deaths.

The latest blow was a study in The Lancet last month that called into question much of the statistical evidence for the vaccine’s effectiveness.

The authors said previous studies had measured the wrong thing: not any actual protection against the flu virus but a fundamental difference between the kinds of people who get vaccines and those who do not.

This contention is far from universally accepted. And even skeptics say that until more effective measures are found, older people should continue to be vaccinated, because some protection against the flu is better than none.

Still, the Lancet article has reignited a longstanding debate over claims that the vaccine prevents thousands of hospitalizations and deaths in older people. “The whole notion of who needs the vaccine and why is changing before our eyes,” said Peter Doshi, a doctoral candidate at M.I.T. who published a paper on the historical impact of influenza in May in The American Journal of Public Health.

The Lancet paper, by Michael L. Jackson and colleagues at the Group Health Center for Health Studies in Seattle, was based on an analysis of medical charts of thousands of elderly members of an H.M.O.

The study found that people who were healthy and conscientious about staying well were the most likely to get an annual flu shot. Those who are frail may have trouble bathing or dressing on their own and are less likely to get to their doctor’s office or a clinic to receive the vaccine. They are also more likely to be closer to death.

Dr. David K. Shay of the Centers for Disease Control and Prevention, a co-author of a commentary that accompanied Dr. Jackson’s study, agreed that these measures of health and frailty “were not incorporated into early estimations of the vaccine’s effectiveness” and could well have skewed the findings.

Not everyone is sold on the significance of the Lancet study. “I think this is another study that provides interesting findings and raises questions,” said Dr. Kristin Nichol, chief of medicine at the Veterans Affairs hospital in Minneapolis. “I don’t think we know yet what the final word is on influenza vaccinations in the elderly.

“I really feel, and I feel very strongly about this, that the public health message should be that vaccines are effective,” she continued. “I don’t think that science is necessarily best hashed out in the media.”

Dozens of studies since 1960 have supported the view that the vaccine is a powerful protector of the elderly, cutting their risk of dying in winter from any cause by almost 50 percent and reducing the risk of hospitalization by nearly 30 percent.

Those findings came from observational studies, in which scientists make inferences about the effect of a treatment on a population by comparing what happens to a group that has the treatment with what happens to an apparently similar group that does not.

There has been only one large study that compared the flu vaccine with a placebo for two random groups of older people in which neither the patients nor the scientists knew which group was receiving which injection. It came to a different conclusion from the observational studies.

Conducted by Dutch researchers and published in 1994 in The Journal of the American Medical Association, it found that in those 60 to 69, the vaccine prevented influenza about 57 percent of the time. In those over 70, the vaccine prevented the flu just 23 percent of the time, though the estimate is imprecise because the study was not designed to look at this age group.

But the influenza vaccine was never put through more placebo-controlled trials, which are considered the gold standard in medical evidence. “I think the evidence base we have leaned on is not valid,” said Lone Simonsen, an epidemiologist and visiting professor at the George Washington University School of Public Health and Health Services in Washington who was not connected with the Lancet study.

In 2005, Dr. Simonsen, who was then at the National Institute of Allergy and Infectious Diseases in Bethesda, Md., published a paper in The Archives of Internal Medicine that found something odd: even though the percentage of older people who got an annual flu shot more than tripled from 1980 to 2001, there was no corresponding drop in the death rate.

That paper included one of the first estimates of how many deaths are actually caused by the flu — a number hard to pin down because doctors seldom confirm flu in their patients with lab tests. Using a statistical model and the best available data, Dr. Simonsen found that influenza probably causes just 5 to 10 percent of all winter deaths in the elderly. But earlier studies had found that the flu vaccine cut an elderly person’s risk of dying by 50 percent.

“You don’t have to do a whole lot of math to realize that doesn’t add up,” said Dr. Lisa A. Jackson of the Group Health Center for Health Studies in Seattle, who has also studied the effectiveness of the flu vaccine in the elderly.

Dr. Jackson at first tried to tease out underlying differences between vaccinated and unvaccinated elderly people by using medical codes — a numerical shorthand that doctors use to classify and record what is wrong with their patients. She and other researchers reasoned that patients with codes for cancer or heart disease, for example, might be very sick, thus skewing the results. When they adjusted for those codes, however, the differences between the vaccinated and unvaccinated groups became even more pronounced. The vaccine looked even more protective.

It was Michael L. Jackson’s thesis project, at the University of Washington, that revealed the flaw in using the codes to differentiate patients.

For the project, Mr. Jackson (no relation to Lisa Jackson) and three other researchers spent almost three years reading medical charts and examining X-rays. They discovered that health-conscious people were more likely to get medical codes for things like heart disease and cancer simply because they went to the doctor more often. But when Mr. Jackson adjusted for measures of frailty — things like lung function, whether people needed help bathing or dressing, and what kinds of medications they took — he found that vaccination had little effect on older people’s risk for pneumonia, the most dangerous complication of the flu.

That finding has a biological basis. Vaccines work by priming the immune system to recognize and respond to incoming threats. Because the immune system slows down with age, older adults do not respond as well to vaccines as younger adults.

A recent study by Dr. Wilbur H. Chen and colleagues at the Center for Vaccine Development at the University of Maryland School of Medicine found that elderly participants needed four times the amount of antigens given in a standard dose of the flu vaccine to have the same kind of immune response as healthy adults under 40. They presented their findings in May at the Annual Conference on Vaccine Research in Baltimore.

Despite these findings, Dr. Shay said the C.D.C. had no plans to change its vaccine recommendations, though he added that the agency had financed studies to look for more effective influenza vaccines for the elderly.

Dr. Simonsen, the epidemiologist at George Washington, said the new research made common-sense infection-control measures — like avoiding other sick people and frequent hand washing — more important than ever. Still, she added, “The vaccine is still important. Thirty percent protection is better than zero percent.”

September 30, 2008
Violations Reported at 94% of Nursing Homes
By ROBERT PEAR

WASHINGTON — More than 90 percent of nursing homes were cited for violations of federal health and safety standards last year, and for-profit homes were more likely to have problems than other types of nursing homes, federal investigators say in a report issued on Monday.

About 17 percent of nursing homes had deficiencies that caused “actual harm or immediate jeopardy” to patients, said the report, by Daniel R. Levinson, the inspector general of the Department of Health and Human Services.

Inspectors received 37,150 complaints about conditions in nursing homes last year, and they substantiated 39 percent of them, the report said. About one-fifth of the complaints verified by federal and state authorities involved the abuse or neglect of patients.

About two-thirds of nursing homes are owned by for-profit companies, while 27 percent are owned by nonprofit organizations and 6 percent by government entities, the report said.

The inspector general said 94 percent of for-profit nursing homes were cited for deficiencies last year, compared with 88 percent of nonprofit homes and 91 percent of government homes.

“For-profit nursing homes had a higher average number of deficiencies than the other types of nursing homes,” Mr. Levinson said. “In 2007, for-profit nursing homes averaged 7.6 deficiencies per home, while not-for-profit and government homes averaged 5.7 and 6.3, respectively.”

On Monday, Mr. Levinson issued a compliance guide for nursing homes that says some homes “have systematically failed to provide staff in sufficient numbers and with appropriate clinical expertise to serve their residents.”

Researchers have found that people receive better care at homes with a higher ratio of nursing staff members to patients.

The inspector general said he had found some cases in which nursing homes billed Medicare and Medicaid for services that “were not provided, or were so wholly deficient that they amounted to no care at all.”

Bruce A. Yarwood, president of the American Health Care Association, a trade group, said: “We know we have to do a better job. We have been doing a better job, in treating pressure sores, managing pain and reducing the use of physical restraints.”

Mr. Yarwood said that the inspection system was broken. “It does not reliably measure quality,” he said. “It does not create any positive incentives.”

More than 1.5 million people live in the nation’s 15,000 nursing homes. The homes are typically inspected once a year and must meet federal standards as a condition of participating in Medicaid and Medicare, which cover more than two-thirds of their residents, at a cost of more than $75 billion a year.

Deficiency rates varied widely among states. The proportion of nursing homes cited for deficiencies ranged from 76 percent in Rhode Island to 100 percent in Alaska, Idaho, Wyoming and the District of Columbia.

The average number of deficiencies also varied, from 2.5 deficiencies per nursing home in Rhode Island to 13.3 per home in Delaware.

Mr. Yarwood said: “Inspectors are subjective and inconsistent. They interpret federal standards in different ways.”

In December, the Bush administration plans to begin using a five-star system to describe the overall quality of care. The best homes will get five stars. The rankings will be published on a federal Web site.

Medicare pays a fixed daily amount for each nursing home resident, with higher payments for patients who are more severely ill. Mr. Levinson said some nursing homes had improperly classified patients or overstated the severity of their illnesses so the homes could claim larger Medicare payments.

November 22, 2008
In Housing Slump, Elderly Forgo Assisted Living
By JACK HEALY

The housing crisis has kept thousands of older Americans who need support and care from moving into retirement communities or assisted-living centers, effectively stranding them in their own homes.

Without selling their houses or condominiums, many cannot buy into retirement homes that require a payment of $100,000 to $500,000 just to move in. So they are scratching themselves off waiting lists, canceling plans with packing services and staying put, in houses that fit well 30 years ago, but over the years have become lonely, too large or too treacherous to navigate.

“It is part of the hidden problem of the recession,” said Larry Minnix, president of the American Association of Homes and Services for the Aging. “Every neighborhood, every family’s got them.”

Facilities that have watched their waiting lists wither and their occupancy rates fall in the last year are now scrambling to bring people through their doors. Some assisted-living centers have called in real estate agents to teach prospective residents about online advertising and how to clean and preen their homes for showings. Others have set up programs with banks to provide bridge loans to homeowners, or are discounting apartments and offering low-interest loans.

The Cedar Community, which provides a range of housing for the elderly in West Bend, Wis., has seen independent-living occupancy rates drop by 4 percent this year. There were so many people waiting for their homes to sell that the facility decided, in some cases, to let new residents pay month-to-month until they could unload their houses and use the proceeds on the facility’s entry deposit.

“We’ve never done that before,” said Tracey MacGregor, a spokeswoman at Cedar Community.

But for people like Ruth Scher, 85, selling their home is a critical first step before moving on, or moving anywhere. Ms. Scher put her two-bedroom condominium in Delray Beach, Fla., on the market last year, but no one has made an offer.

In the 34 years since she moved to South Florida, Ms. Scher’s husband has died, the siblings who moved south from New York to join her have died, and her friends have moved away. She is recovering from a fall that broke her clavicle and suffers from arthritis in one shoulder, and she says it is time to move back.

“It’s lonesome,” Ms. Scher said. “So many other people have passed away or moved away. It’s very lonely. The children would love me to come up and I would love to, but I just can’t sell.”

Ms. Scher hoped to move to a retirement community in Cornwall, N.Y., where she has friends. But in the year her home sat on the market, she could not even find a broker willing to sell the property, she said. She finally de-listed her condominium.

There is no way to say how many older Americans are in similar straits, as no statistics track how many of America’s 4.27 million unsold homes are owned by people 65 or older. But industry groups and administrators at retirement homes call the problem a growing one, which worsened as the financial crisis spread from real estate to lending markets. It has been felt worst in regions hit hardest by the housing bust.

“It remains to be seen whether we have a short-term stress, or whether we’re facing a crisis,” said Mr. Minnix, of the Association of Homes and Services for the Aging. “We’re into brand new territory here. It is deeper and potentially broader.”

Across the country, occupancy rates for independent and assisted-living facilities have fallen slightly in the last year, by about 2 percent through the middle of 2008, according to the National Investment Center for the Seniors Housing and Care Industry.

But the problem is playing out acutely in hard-hit areas like Florida, where the vacancy rate at some facilities is up 20 percent to 30 percent over last year, said Paul Williams, director of government relations for the Assisted Living Federation of America. At Luther Manor, a retiree community in Milwaukee, the number of residents moving into independent living has dropped 20 percent this year. In southern Ohio, 65 percent of the people who visited the Bristol Village retirement community this year said they could not buy a unit because their homes were still hanging around their necks.

For these businesses, each occupied room generates thousands of dollars each year. Retirement condos charge monthly fees ranging from a few hundred dollars to $5,000, while the average price for private-pay care in assisted living is $3,013 per month, or $36,156 per year, according to a MetLife study.

At the Crosby Commons assisted-living center in Shelton, Conn., where waiting lists that once ran two years or more have shrunk to six months, some residents who moved before selling their homes are spending through their savings as they wait, said Lois Poultney, the center’s director. One resident had to move from Crosby’s free-market homes to its subsidized rent-controlled apartments, Ms. Poultney said.

“I’m hearing it over and over again: ‘Mom needs to sell her house before she can afford to move in,’ ” she said.

There are signs some families and retirees are turning to adult day care services as a stopgap. Providers say their business has spiked as people look for an alternative to continuing care or home aides to provide food, companionship and therapeutic services. But Mr. Williams of the Assisted Living Federation said that people who need more day-to-day care, those who have trouble getting up stairs or who need someone to check on them, were taking a risk by staying at home.

“When they’re coming in at 85, they’re coming in very frail and needing services,” he said. “They can’t wait this out. They need the care when they need the care. That’s the scary part. You have people putting it off when they need care right now.”

For Katherine Styberg, 84, that moment of realization came when she slipped on a patch of ice in February and fractured a vertebra. She has to use a cane when she walks now, and she says she has been thinking about how she lives alone, and if she fell in her two-bedroom condominium in Milwaukee, no one could catch her or help her up.

The real estate broker calls Ms. Styberg a day before bringing potential buyers to see her apartment, and a few have come to look around, but no one has made an offer yet.

As parents linger in their homes, they say their children start to worry. Some adult children are even facing financial hardships if they cannot sell their parents’ homes.

In April, Ruth Swessel, 84, of Milwaukee, had a stroke that aggravated the effects of her aging, leaving her unable to follow “Meet the Press” or read the political magazines she once loved. Her daughter, Laura Westling, had to put her into skilled care, and the family began the process of selling Ms. Swessel’s house to pay for the facility’s $60,000 annual cost.

The house has been sitting on the market since the summer, and Ms. Swessel’s family has lowered the price twice, to $174,500 from $189,900, but they have not been able to close a deal. Her children are spending her investments to pay for her care, but Ms. Westling said they did not know what they would do once that money ran out.

“It’s not easy,” she said.

As stock markets have slid in the last year, homes have become a more critical source of wealth for retirees who have watched their mutual funds and 401(k) accounts hollow out. Next to accrued Social Security benefits, housing is the single greatest asset for people 60 to 70 years old, making up 22 percent of their total wealth and outweighing investments and pensions, according to the Center for Retirement Research. For retirees like Herman McHan, who watched the value of his mutual funds fall to $35,000, from $70,000, or Sylvia Merlin, whose portfolio has lost nearly $200,000 of value, owning an interminably on-the-market home compounds the worries of their dwindling investments.

For Ms. Merlin, it is a disconcerting place to be at age 93. She said she and her late husband, Al, had lived modestly to raise their four children, taking one vacation a year, to the Jersey Shore. She is on oxygen now, and finds it harder to get around her fifth-floor apartment outside of Philadelphia. The doorman’s wife takes her to the hairdresser on Fridays, but Ms. Merlin said she wanted more consistent care.

“I’m going to be 94, and I need help,” she said. “Making the bed is difficult. I need a little help taking a shower. Those things are difficult. I was a great cook, but I really don’t cook anymore. I bought the TV dinners, and they’re pretty lousy.”

No one has made an offer on her condominium, and Ms. Merlin said the retirement home had refunded the $1,000 deposit on the $130,000 unit she hoped to buy. Now, instead of moving, she said she had decided to stay.

“I just couldn’t go anywhere until I sold my apartment,” she said. “I and a lot of other oldsters are stuck.”

A drug used for stroke patients may help sharpen middle-aged brains, researchers are reporting.

In the latest development in the quest for cognitive enhancers, researchers found the drug Fasudil significantly improves learning and memory in middle-aged rats.

If proven in humans, the drug may one day help blunt the impact of normal aging "or even enhance learning and memory throughout the life span," the American Psychological Association said in an announcing the findings, published in the February issue of the journal Behavioral Neuroscience.

"I do think that we are going to move into that area,"says lead author Matthew Huentelman, an investigator at the non-profit Translational Genomics Research Institute in Phoenix, Arizona.

"Really, we stumbled on this drug, and what do we do with it? Our drug is only supposed to be used for sick people. Can it be used for healthy individuals as well? It's a tough question."

University students are already using Ritalin and other prescription amphetamines to boost their grades. A survey by Nature, a top science magazine, last year revealed one-fifth of its global readership admitted to using "cognition-enhancing" drugs to help them concentrate. And seven prominent neuroscientists and ethicists recently argued in the same journal that not only is the trend likely to grow, but that "mentally competent adults" should be free to use safe cognitive enhancements with-out being made out to be felons.

But is using brain enhancers to boost productivity and give people a competitive edge cheating, like doping in sports?Would workers need protection from pressure from employers to "enhance?"

Several drugs now being tested in humans may help stave off normal, age-related memory decline in healthy people, and many drugs used to treat psychiatric and neurological problems can also increase how quickly and accurately people think.

The Arizona study began several years ago, when researchers identified a gene that plays a role in memory in humans. Next they looked for drugs that affect the gene's function. They tested Fasudil, a drug that improves blood flow to the brain, in rats.

The dosed rats performed significantly better on water maze testing learning and memory than rats given a saline solution. The doped rodents performed more like four-month old rats, or the equivalent of a teenager in human years.

"It was a pretty significant improvement in their memory performance," Huentelman says. There were no side-effects, and the drug has been shown to be safe and well tolerated when used in humans. The findings, and the relative safety of the drug, support its potential as a "cognitive enhancer in humans," the researchers report.

Huentelman worries about cognitive-enhancers creeping into high schools and colleges, but if the drugs can push out the onset of Alzheimer's disease or other dementias by even five years, "that's a massive impact.

"To me, aging is the worst disease, because it happens to all of us.

"Improving our ability to age, aging more gracefully as they famously say, is a benefit for all."

Four of the researchers hold stock in the drug company that owns the rights to develop this drug.

When an old lady died in the geriatric ward of a small hospital near Dundee , Scotland , it was believed that she had nothing left of any value.
Later, when the nurses were going through her meager possessions, they
found this poem. Its quality and content so impressed the staff that
copies were made and distributed to every nurse in the hospital.
One nurse took her copy to Ireland. The old lady's sole bequest to
posterity has since appeared in the Christmas edition of the News
Magazine of the North Ireland Assn. for Mental Health. A slide presentation has also been made based on her simple, but eloquent
poem. And this little old Scottish lady, with nothing left to give to the world, is now the author of this 'anonymous' poem winging across the Internet:
------- ----------------------------------------------------

Crabby Old Woman

What do you see, nurses?
What do you see?
What are you thinking,
When you're looking at me?

A crabby old woman,
Not very wise,
Uncertain of habit,
With faraway eyes..

Who dribbles her food,
And makes no reply,
When you say in a loud voice,
'I do wish you'd try!'

Who seems not to notice,
The things that you do,
And forever is losing,
A stocking or shoe

Who, resisting or not
Lets you do as you will,
With bathing and feeding,
The long day to fill?

Is that what you're thinking?
Is that what you see?
Then open your eyes, nurse,
You're not looking at me.

I'll tell you who I am,
As I sit here so still,
As I do at your bidding,
As I eat at your will.

I'm a small child of ten,
With a father and mother,
Brothers and sisters,
Who love one another.

A young girl of sixteen,
With wings on her feet,
Dreaming that soon now,
A lover she'll meet.

A bride soon at twenty,
My heart gives a leap,
As I make the vows
That I promised to keep.

At twenty-five now,
I have young of my own,
Who need me to guide,
And a secure happy home.

A woman of thirty,
My young now grown fast,
Bound to each other,
With ties that should last.

At forty, my young sons,
Have grown and are gone,
But my man's beside me,
To see I don't mourn.

At fifty once more,
Babies play round my knee,
Again we know children,
My loved one and me.

Dark days are upon me,
My husband is dead,
I look at the future,
I shudder with dread.

For my young are all rearing
Young of their own,
And I think of the years,
And the love that I've known.

I'm now an old woman,
And nature is cruel,
'Tis jest to make old age,
Look like a fool.

The body, it crumbles,
Grace and vigour depart,
There is now a stone
Where I once had a heart...

But inside this old carcass,
A young girl still dwells,
And now and again,
My battered heart swells.

I remember the joys,
I remember the pain,
And I'm loving and living
Life over again.

I think of the years,
All too few, gone too fast,
And accept the stark fact
That nothing can last.

So open your eyes, people,
Open and see,
Not a crabby old woman;
Look closer - see ME!!

Remember this poem when you next meet an old person who you might brush aside without looking at the young soul within.

Healthy older people spending money on computer games and websites to ward off mental decline are giving their wallets more of a workout than their brain, according to a U.S. study.

Dr. Peter J. Snyder of Lifespan Affiliated Hospitals in Providence, R. I., reviewed the scientific evidence for the benefits of these "brain exercise"programs says but found they did not live up to expectations.

"There are some things that we could be doing that have much more rigorous data to support their application."

However, Snyder and his team note in the journal Alzheimer's&Dementia that types of "brain training" are known to help people with memory problems function better, but their benefits for those who don't have measurable cognitive impairment isn't clear.

Meanwhile, Snyder said in an interview, the market for these products has swelled from$2 million US in 2005 to an estimated $225 million this year.

To review evidence on the benefits of cognitive training for healthy older people, Snyder and his colleagues analyzed 10 randomized controlled trials of a variety of approaches, ranging from a popular computer-based program to individualized piano lessons.

While there was some evidence that brain training helped people's immediate performance on tasks related to the training, there was no evidence that the effects could be generalized to other areas of mental function, Snyder and his colleagues found. Further, just half of the studies included extended followup, so evidence for long-term benefits was slim.

But social and intellectual engagement in day-to-day life, from reading to grandchildren to doing crossword puzzles, is "probably just as effective or more effective" than any formal brain exercise program, he added.

Further, he pointed out, these activities are free.

Snyder said there is strong scientific evidence that being physically active every day preserves cognitive function. Because cardiovascular disease and Type 2 diabetes are both known to contribute to mental decline, he added, exercising and taking other steps to maintain heart health and a healthy weight will help keep the brain healthy, too.

March 31, 2009
Treating an Illness Is One Thing. What About a Patient With Many?
By SIRI CARPENTER

Mazie Piccolo has so many health problems it’s hard to keep track. Congestive heart failure makes her short of breath and causes her legs to swell. An abnormal heart rhythm raises her risk for stroke. Arthritis in her knees makes it hard for her to get around, and she can no longer drive.

Mrs. Piccolo, 84, of Rosedale, Md., also has osteoporosis, and she has fallen several times in the past few years, once breaking her pelvis. On top of all these medical ailments and others — high cholesterol, high blood pressure, gastric reflux — she has a history of depression, and it is sometimes hard for her to care for her husband, who is even frailer than she is.

Strictly by the book, Mrs. Piccolo should be taking 13 different medications — an expensive, confusing cocktail that has proved too much for her to manage. Other medications that might be advisable cause intolerable side effects, and the more drugs she takes, the greater the risk of dangerous drug interactions.

What is striking about her predicament is not how rare it is, but how common. Two-thirds of people over age 65, and almost three-quarters of people over 80, have multiple chronic health conditions, and 68 percent of Medicare spending goes to people who have five or more chronic diseases.

As a group, patients like Mrs. Piccolo fare poorly by any measure. They linger in hospitals longer, experience more serious preventable health complications and die younger than patients with less complex medical profiles.

Yet people with multiple health problems — a condition known as multimorbidity — are largely overlooked both in medical research and in the nation’s clinics and hospitals. The default position is to treat complicated patients as collections of malfunctioning body parts rather than as whole human beings.

“Very often, there is nobody looking at the big picture or recognizing that what is best for the disease may not be best for the patient,” said Dr. Mary E. Tinetti, a geriatrician at the Yale School of Medicine.

And treating one disease in isolation, she added, can make another disease worse. In controlling diabetes, for example, doctors often seek to reduce levels of a blood-sugar marker called hemoglobin A1C. “But we know that for some people with complicated diseases, that’s not always the best move,” Dr. Tinetti said.

Mrs. Piccolo is being treated by Dr. Cynthia M. Boyd, a Johns Hopkins University geriatrician whose research focuses on patients with multiple chronic conditions.

“Doing right by patients like this is tremendously challenging,” Dr. Boyd said. “Would she get the most benefit from lowering her blood pressure or cholesterol level, or from being treated for her osteoporosis, or from taking warfarin for stroke prevention? Or is it more important to treat her depression so she can manage her overall health better, or to try to improve her ability to physically get around?”

The medical file for Fred Powledge, 74, is four inches thick, with more than a dozen current diagnoses, including diabetes, gout, chronic obstructive pulmonary disease, compressed vertebrae, three replacement joints, two replacement eye lenses and arthritis.

Mr. Powledge, a Maryland writer, takes almost a dozen pills a day, as ordered by six physicians.

“Good luck and a lot of sleuthing on my part have given me doctors whom I trust and who are mostly aware of interactions among the drugs they prescribe,” he said in an e-mail message. “But what’s missing is someone who can look at the big picture and see my health as a whole.

“That falls to me alone, with the help of my very wise wife and frequent visits to reliable Web sites,” he continued. “As our population ages, we need some kind of overseer to juggle all the diagnoses and prescriptions and look for conflicts and duplications. This would also help to counteract the notion in many people’s minds that the doctor knows best — because often the doctor doesn’t.”

In a medical system geared toward individual organs and diseases, there is no champion for patients with multiple illnesses — no National Institute on Multimorbidity, no charity Race for the Multimorbidity Cure, no celebrity pressuring Capitol Hill for more research.

And because studies involving uncomplicated populations are cheapest and easiest to interpret, patients with multiple diseases are routinely shut out of drug trials. A 2007 study found that 81 percent of the randomized trials published in the most prestigious medical journals excluded patients because of coexisting medical problems.

“We often don’t know what the real safety or efficacy is for patients with multiple illnesses,” said Dr. W. Douglas Weaver, president of the American College of Cardiology.

Pharmaceutical companies are required to study how well particular drugs and medical devices work in the real world, after they’ve gotten government approval. In theory, such post-marketing studies should shed light on how best to treat patients who have complex medical problems. But the studies tend to include only a small fraction of patients receiving treatment, Dr. Weaver said.

Comprehensive data registries that track all patients at a given hospital or clinic are more promising, he said. But he added that unless the federal government stepped in to support such registries and pay doctors for participating, they might not be sustainable.

Because so little research includes complicated patients, physicians have little scientific evidence on which to base their care. In a 2005 study, Dr. Boyd and colleagues analyzed influential, evidence-based clinical practice guidelines used to treat nine of the most common chronic diseases, among them osteoporosis, arthritis, Type 2 diabetes and high cholesterol.

Fewer than half the guidelines specifically addressed patients with multiple illnesses, and most were limited to patients with only one coexisting disease or a small number of closely related diseases. “We’re so far away from having perfect evidence about how to help patients with complex health problems,” Dr. Boyd said.

Lacking solid guidance, doctors make their best guesses about whether a particular guideline is applicable to the patient, said Gerard F. Anderson, a professor of health policy and management at the Bloomberg School of Public Health at Johns Hopkins. And “their best guesses,” he went on, “vary all over the map.”

Time pressures intensify the doctors’ predicament. A typical 15-minute appointment leaves too little time to weigh the risks and benefits of a complex treatment plan, much less to fully consider the patient’s preferences and priorities.

“We don’t actually know how to weigh evidence across diseases,” said Dr. Boyd, of Johns Hopkins, “and we also don’t know the best ways of communicating to patients what we do and don’t know.”

Quality-improvement measures, which tie doctors’ compensation to how closely they follow evidence-based practice guidelines, further complicate matters, and some worry that they provide a financial incentive for physicians to sacrifice individualized decision-making.

“Doctors know that it’s not right for someone to be on 15, 18, 20 medications,” said Dr. Tinetti, the Yale geriatrician. “But they’re being told that that’s what’s necessary in order to treat each of the diseases that the patients in front of them have.”

Changing that will require a major investment in research, guidelines and quality measures that include the kinds of complicated cases doctors see every day.

“I think everyone realizes that we need to figure out how to integrate care for our elderly patients with multiple chronic conditions,” said Dr. Ardis D. Hoven, an internist in Lexington, Ky., who is a trustee of the American Medical Association. “But we’ve got a long way to go. We’re just now beginning to verbalize this.”

Tyrone Turner for The New York Times
ANOTHER DAY Faye Milbourne, a former Verizon worker who went back to school to become a teacher, waits for students to arrive at an elementary school in Virginia Beach.

Finding their retirement nest eggs short, many are doing whatever it takes to start a second career.

Slide Show: Back in School Again
A Quest for a Home, Put on Hold
By JODI RUDOREN
Her next move was supposed to be her last, but her well-laid plans to enter a retirement community have been frustrated by the sagging market.

Experienced, Eager to Serve, Will Travel
By ELIZABETH POPE
Within two days of President Obama’s Inaugural Address, online applications to the Peace Corps spiked, and many older Americans have responded to the call to serve.

A Move to Expand Volunteer Ranks | How to Enlist
Calling for Financial Advice . . . and Reassurance
By CHARLES DELAFUENTE
Hotlines provided by employers or groups they belong to have experienced a spike in activity from callers seeking mostly long-term advice.

More Are Spending Less to Get Away From It All
By STEFANI JACKENTHAL
While this may seem like a peculiar time to take a dream vacation, the prices are right if you have the cash.

Slide Show: Travel Deals for Tough Times
Doctors Are Opting Out of Medicare
By JULIE CONNELLY
Many people, just as they become eligible for Medicare, discover that the insurance rug has been pulled out from under them.

Times Topics: Medicare
Protecting Retirement Accounts From Creditors
By DEBORAH L. JACOBS
Even at today’s depressed values, it’s important to protect your retirement accounts from creditors.

RESIDENTS aged over 55 are being urged to take up fitness activities aimed at promoting healthy lifestyles for older people.

The Say Go! scheme covers a range of activities at different venues across the borough, including sports, dance and yoga lessons.

It is organised by Age Concern Barnet, with funding from Barnet Council and Sport England.

The classes are run in partnership with a number of faith and community groups, including the Barnet African Caribbean Association, Barnet Asian Old People's Association and the Anand Day Centre, but anyone aged over 55 is welcome to attend.

A new ten-week course of tai chi was launched on Tuesday, aimed specifically at members of the borough's Ismaili Muslim community, to be held at the North London Jamatkhana, in East End Road, Finchley.

The classes will take place during the day and also offer a chance for members to socialise after the session.

Councillor Lynne Hillan, cabinet member for community services, said: "The Say Go! scheme provides a very important service for older people living in Barnet and helps to work towards the council's corporate priority of a strong and healthy borough.

"I hope that many of our residents aged over 55 take the opportunity to take part in one or more of the Say Go! classes as they continue to be rolled out and enhanced throughout the coming year."

For more information visit the council website at barnet.gov.uk/activities-for-older-people or call the council on 020 8359 2000.

Canada will soon face a serious crisis in caring for the elderly unless policymakers act now to head it off, says a Carleton University researcher.

Gabrielle Mason, a PhD student in political science, says lifestyle changes combined with an aging population are about to create a serious elder-care crunch in Canada.

Mason said that policymakers should keep "Canada's aging society in mind so that the (government) can adjust and design infrastructure, policies, plans and resources which celebrate increased longevity and reduce dependencies on family."

By 2015 there will be more people in Canada over the age of 65 than under the age of 15, according to Statistics Canada's most recent population projections. And the number of seniors is expected to double over the next 25 years. "Canadian citizens deserve and should expect good quality of life in their elder years," said Mason. "A minimum level of care shouldn't be considered a luxury."

Mason argued that investing in services now to help the elderly find care will dramatically cut costs to taxpayers later on.

She suggested several reasons a crisis is looming. Most elderly people in Canada are currently cared for by their family, but the traditional caregivers-- younger, female family members--now have full-time jobs and are less able to look after their relatives. Also, baby boomers who married and had children later in life or had fewer children and moved frequently may live far away from their kids and have no one nearby to care for them.

Reasonably healthy elderly people may simply need help with shopping or heavy housework, as well as emotional support. But those with more serious physical and mental impairments may require 24-hour care.

In her research, Mason found that 90 per cent of Canadians would prefer to spend their final years at home, favouring help from formal services over family care.

"Relying on family members' help for care often evokes feelings of indebtedness and clashes with closely held ideas about independence and self-reliance," she wrote.

The Senate committee on aging, which submitted its final report in April, found that caring for clients who are permitted to stay at home costs less per year than caring for those who must enter a care facility --even when the informal caregiving work of family members is allocated a financial cost.

They found that a patient in community care will cost about $37,000 per year, compared to $87,000 in a facility.

Artificial cats and other man-made companions could be keeping Britain's elderly company within three years if society can be persuaded to start experimenting with robots.

A report by the Royal Academy of Engineering published on Thursday shows robot soldiers and surgery devices are rapidly being developed, but the legal and ethical debate is lagging.

"This is not constrained by the technological possibility of it so much as by the desire to do it--and that is bound up with all sorts of social factors," said Prof. Will Stewart of Southampton University, who contributed to the report.

As well as robotic pets, autonomous systems could be morphed into robot babysitters, artificial therapists and social or even sexual companions.

With Britain's elderly population set to grow about 50 per cent by 2020, robotic companions could also help monitor the health of Britain's increasingly grey population.

"It is not a complete replacement for your kid calling you once a week. What you want is continuous attention and that is very difficult," said Stewart.

A robotic pet could help raise the alarm in the case of an accident, monitor fridge contents, and voice prompts could remind them to switch off the heating.

The ethical challenges facing a robotic revolution include concerns that artificial pets or helpers could lead to social isolation for the elderly.

September 19, 2009
Helping the Aged Leave Nursing Homes for a Home
By JOHN LELAND

PHILADELPHIA — Walter Brown never wanted to live in a nursing home, but when he had a stroke two years ago, he saw little choice. Mr. Brown, 72, could not walk, use his left arm or transfer himself into his wheelchair.

“It was like being in jail,” Mr. Brown said on a recent afternoon. “In the nursing home you’ve got to do what they say when they say it, go to bed when they tell you, eat what they want you to eat. The food was terrible.”

But recently state workers helped Mr. Brown find a two-bedroom apartment in public housing here, which he shares with his daughter. “It just makes me more relaxed, more confident in myself,” he said, speaking with some difficulty, but with a broad smile. “More confident in the future.”

A growing number of states are reaching out to people like Mr. Brown, who have been in nursing homes for more than six months, aiming to disprove the notion that once people have settled into a nursing home, they will be there forever. Since 2007, Medicaid has teamed up with 29 states to finance such programs, enabling the low-income elderly and people with disabilities to receive many services in their own homes.

The program in Pennsylvania provides up to $4,000 in moving expenses, including a furniture allowance and modifications to the apartment, and Mr. Brown has a home health aide every morning and a care manager to arrange for services like physical therapy. The new programs, financed largely by $1.75 billion from Medicaid, are a sharp departure from past practices, where Medicaid practically steered people into nursing homes.

“Medicaid has had an institutional bias in favor of nursing homes,” even for people who do not need them, said Gene Coffey, a staff lawyer at the nonprofit National Senior Citizens Law Center. “Federal law requires states to provide nursing home services. They don’t have to provide home or community-based services.”

For Mr. Brown, the transition to his own home has changed his life, he said. Now, with his motorized wheelchair, he travels the city on public buses, visiting friends in other neighborhoods.

“It’s a great feeling,” he said. “In the nursing home I got up at 5 o’clock in the morning, then the rest of the day was just watching the TV or my VCR. I wanted to be able to get out and see people, see the world. I didn’t want to be confined. Now I go where I want to go.”

States and the federal government hope to save money, though research about cost savings has so far been inconclusive. A recent study by researchers at the University of California, San Francisco, found that home care costs taxpayers $44,000 a year less than a nursing home stay — though this number cannot be used to estimate total savings, because often home-based services replace family care, not nursing home care.

About 1.5 million Americans are living in nursing homes.

“It’s amazing how quickly people can end up in a nursing home,” said Jean Janik, the director of community living options at the nonprofit Philadelphia Corporation for Aging. “Say you’re a single man and have a stroke, and need to go into a nursing home to rehab. You’re elderly so you don’t quite bounce back quickly. After 60 days, Medicare doesn’t pay any longer, so you need a Medicaid grant to stay in the nursing home. Then your Social Security will go to the nursing home.”

Many lose their apartments and regular support from family members, Ms. Janik said.

“We meet people who say, ‘I went to the hospital and next thing I know, here I am. I don’t know what happened to my apartment.’ ” Ms. Janik added, “We go and check, and it’s not in their name. Especially if they don’t have a strong family support system in place. A lot of people just think, Uncle Joe fell and broke his hip and now he’s in a nursing home, so be it, that’s where he’ll be. People don’t realize they can get services in their home.”

Each participating state has designed its own program, called Money Follows the Person. The federal government, which shares Medicaid costs, provides extra financing for the first year.

Some experts worry that the programs will end up transferring some of the expenses of caring for the elderly or the disabled to their family members.

Carol Irvin, a senior researcher at Mathematica Policy Research has been contracted by Medicare and Medicaid Services to study the costs of the program in its first five years.

“It could be shifting costs onto a person’s relatives,” Ms. Irvin said. “But even if it’s not saving money, a lot of people believe living in the community is the right thing for individuals.”

Elizabeth Kamara, 72, spent 18 months in a nursing home after having her left foot amputated because of diabetes. Mrs. Kamara can get around using a walker, but in the nursing home she spent whole days in a wheelchair.

“I just let people do things for me,” she said. “They say, ‘If you fall, we’ll get in trouble. Please sit down.’ ”

Mrs. Kamara has moved into a independent living facility, where she cooks dishes from her native Sierra Leone and navigates the hallways on her own. She gives herself insulin injections and gets a friend to drive her to doctors’ appointments. An aide comes twice a week to help clean. “This is my home; I’m free,” she said. “In the nursing home it was two persons in one room. Here I have my privacy. I can get my hair done, my nails done.”

Susan C. Reinhard, a senior vice president of the AARP Public Policy Institute, said of Money Follows the Person: “It’s gotten Congress’s attention, and shown that people can leave a nursing home. That is a wake-up.”

For Esther Pinckney, 88, who ended up in a nursing home after a stroke, moving out has been literally a breath of fresh air. Ms. Pinckney now lives in a bright subsidized apartment where home aides visit twice a day.

“What didn’t I like about the nursing home?” she asked recently. “What would you like about smell, smell, smell, morning, noon and night?”

Because Ms. Pinckney lost her apartment and furniture while she was in the nursing home, the Philadelphia Corporation for Aging bought her new furniture and a microwave oven. Before, she said, her Social Security check went to the nursing home; now she pays 30 percent of her check for her rent. “I couldn’t even buy a soda,” Ms. Pinckney said. “You want to be independent, don’t you? That’s what I wanted.”

Life on her own has not been perfect, she admitted. Aides often fail to show up or spend their time talking on the telephone.

But her pastor takes her to church four times a week, and she can go to stores near her building. If her health should fail again, she said, she did not like to think about going back into a nursing home.

Slowly, you see it happening to your parents: a jar that does not open, important dates forgotten, missed appointments, the feeling of being lost at times. One day, there is a rapid escalation — a bad fall followed by a slow recovery, or an illness that never leaves. Realisation strikes: you are becoming a parent to your own parents.

November is National Family Caregiver’s Month. Studies indicate that healthy caregivers have a better outlook on life. Photo: Courtesy of iStockPhoto.com

Caring for the elderly is highly revered in Islam, and its importance was frequently underlined during the commemoration of Mawlana Hazar Imam’s Golden Jubilee. In the United States, November is National Family Caregivers Month — an event that pays tribute to over 16 million people in North America who provide care for a loved one. The month recognises those who spend their time and resources to care for their aging parents and other family members who are unable to take care of themselves.

Dr Sultan Ali Lakhani is the Director of Geriatric Psychiatry at Virginia Commonwealth University. He sees approximately 75–100 new cases of dementia, depression, and other mental illnesses each month among his elderly patients. Dr Lakhani, who also supports family caregivers by offering them education and counselling to connect them with resources in the community, shares some tips for caregivers:

Become an educated caregiver

“An educated caregiver is a better caregiver,” advises Dr Lakhani. It is important that those providing care learn as much as they can about the problems that their loved ones are facing in order to provide the best form of assistance. Confer with your loved ones’ health care providers and ask them for suggested reading materials. “If your mother has Alzheimer’s disease, try to learn about the process of the disease and how it will affect her memory, behaviour, and day to day functions in future,” says Dr Lakhani.

Plan for effective care

If it is not managed well, providing care can be overwhelming at times. Dr Lakhani suggests making lists of important activities. “If you are setting up a weekly pill box, do so on the same day of the week each time,” he says. Using online or desk calendars can be beneficial.

Look after your own wellbeing

Maintaining the physical, mental, and emotional wellbeing of the person providing care is essential for effective and quality care giving. Studies indicate that healthy caregivers have a better outlook on life. Pursuing hobbies of interest can make those providing care feel energised and refreshed even if it pulls them away from their duties for a short time. It is also important for caregivers not to postpone their own medical checkups. Above all Dr Lakhani advises steering clear of feeling guilty when things go wrong: “Be gentle and forgiving to yourself if you make a mistake in providing care.”

Cultivate a sense of humour

Laughter is the best medicine. Dr Lakhani urges his patients to find humour in everyday life. “Caregiving is hard work. Allow yourself time to laugh when the road ahead looks bleak,” he advises.

Actively seek support

The US Administration on Aging suggests that caregivers should ask for support if they feel overwhelmed. Develop a support system for yourself by inviting family and close friends to share the load. Actively solicit support even if it means having someone sit in for a few hours. “Also take advantage of community resources that are available out there,” says Dr Lakhani.

We like to think that in days gone by, the young venerated the elderly. But that wasn’t always so. In “As You Like It,” Shakespeare’s morose character, Jaques, calls old age “second childishness and mere oblivion.” Walt Whitman hoped that the tedium and pettiness of his senior years would not infect his poetry.

Developmental psychologists, when they treated old age at all, often regarded it as a period of withdrawal. The elderly slowly separate themselves from the world. They cannot be expected to achieve new transformations. “About the age of fifty,” Freud wrote, “the elasticity of the mental processes on which treatment depends is, as a rule, lacking. Old people are no longer educable.”

Well, that was wrong. Over the past few years, researchers have found that the brain is capable of creating new connections and even new neurons all through life. While some mental processes — like working memory and the ability to quickly solve math problems — clearly deteriorate, others do not. Older people retain their ability to remember emotionally nuanced events. They are able to integrate memories from their left and right hemispheres. Their brains reorganize to help compensate for the effects of aging.

A series of longitudinal studies, begun decades ago, are producing a rosier portrait of life after retirement. These studies don’t portray old age as surrender or even serenity. They portray it as a period of development — and they’re not even talking about über-oldsters jumping out of airplanes.

People are most unhappy in middle age and report being happier as they get older. This could be because as people age they pay less attention to negative emotional stimuli, according to a study by the psychologists Mara Mather, Turhan Canli and others.

Gender roles begin to merge. Many women get more assertive while many men get more emotionally attuned. Personalities often become more vivid as people become more of what they already are. Norma Haan of the University of California, Berkeley, and others conducted a 50-year follow-up of people who had been studied while young and concluded that the subjects had become more outgoing, self-confident and warm with age.

The research paints a comforting picture. And the nicest part is that virtue is rewarded. One of the keys to healthy aging is what George Vaillant of Harvard calls “generativity” — providing for future generations. Seniors who perform service for the young have more positive lives and better marriages than those who don’t. As Vaillant writes in his book “Aging Well,” “Biology flows downhill.” We are naturally inclined to serve those who come after and thrive when performing that role.

The odd thing is that when you turn to political life, we are living in an age of reverse-generativity. Far from serving the young, the old are now taking from them. First, they are taking money. According to Julia Isaacs of the Brookings Institution, the federal government now spends $7 on the elderly for each $1 it spends on children.

Second, they are taking freedom. In 2009, for the first time in American history, every single penny of federal tax revenue went to pay for mandatory spending programs, according to Eugene Steuerle of the Urban Institute. As more money goes to pay off promises made mostly to the old, the young have less control.

Third, they are taking opportunity. For decades, federal spending has hovered around 20 percent of G.D.P. By 2019, it is forecast to be at 25 percent and rising. The higher tax rates implied by that spending will mean less growth and fewer opportunities. Already, pension costs in many states are squeezing education spending.

In the private sphere, in other words, seniors provide wonderful gifts to their grandchildren, loving attention that will linger in young minds, providing support for decades to come. In the public sphere, they take it away.

I used to think that political leaders could avert fiscal suicide. But it’s now clear change will not be led from Washington. On the other hand, over the past couple of years we’ve seen the power of spontaneous social movements: first the movement that formed behind Barack Obama, and now, equally large, the Tea Party movement.

Spontaneous social movements can make the unthinkable thinkable, and they can do it quickly. It now seems clear that the only way the U.S. is going to avoid an economic crisis is if the oldsters take it upon themselves to arise and force change. The young lack the political power. Only the old can lead a generativity revolution — millions of people demanding changes in health care spending and the retirement age to make life better for their grandchildren.

It may seem unrealistic — to expect a generation to organize around the cause of nonselfishness. But in the private sphere, you see it every day. Old people now have the time, the energy and, with the Internet, the tools to organize.

July 28, 2010
Technologies Help Adult Children Monitor Aging Parents
By HILARY STOUT

IN the wee hours of July 14, Elizabeth Roach, a 70-year-old widow, got out of bed and went to the living room of her Virginia ranch home. She sat in her favorite chair for 15 minutes, then returned to bed.

She rose again shortly after 6, went to the kitchen, plugged in the coffee pot, showered and took her weight and blood pressure. Throughout the morning, she moved back and forth between the kitchen and the living room. She opened her medicine cabinet at 12:21 and closed it at 12:22. Immediately afterward, she opened the refrigerator door for almost three minutes. At 1:36, she opened the kitchen door and went outside.

All this information — including her exact weight (126 pounds) and blood pressure reading (139/9 — was transmitted via the Internet to her 44-year-old son, Michael Murdock, who reviewed it from his home office in suburban Denver.

All was normal — meaning all was well.

“Right now she’s not home,” Mr. Murdock said. That he deduced because the sensors he had installed throughout his mother’s home told him that the kitchen door — which leads outside — had not been reopened since 1:36, more than an hour earlier. The opening of the medicine cabinet midday confirmed to him that his mother had taken her medicine. And he was satisfied that she had eaten lunch because the refrigerator door was open more than just a few seconds.

In the general scheme of life, parents are the ones who keep tabs on the children. But now, a raft of new technology is making it possible for adult children to monitor to a stunningly precise degree the daily movements and habits of their aging parents.

The purpose is to provide enough supervision to make it possible for elderly people to stay in their homes rather than move to an assisted-living facility or nursing home — a goal almost universally embraced as both emotionally and financially desirable. With that in mind, a vast spectrum of companies, from giants like General Electric to start-ups like iReminder of Westfield, N.J., which has developed a system to notify families if loved ones haven’t taken their medicine, are looking for a piece of the market of families with an aging relative.

Many of the systems are godsends for families. But, as with any parent-child relationship, all loving intentions can be tempered by issues of control, role-reversal, guilt and a little deception — enough loaded stuff to fill a psychology syllabus. For just as the current population of adults in their 30s and 40s have built a reputation for being a generation of hyper-involved, hovering parents to their own children, they now have the tools to micro-manage their aging mothers and fathers as well.

Wendy A. Rogers, a psychology professor at Georgia Tech, who has studied such systems and seniors’ reactions to them, recalled a man who went into high alert when a sensor system showed a high level of activity in a room of his mother’s home. He called her to find out what was wrong — and it turned out that she had decided to paint the sunroom.

“I think the critical question is: Is this something the parent wants?” said Nancy K. Schlossberg, a counseling psychologist and professor emerita at the University of Maryland. She compared monitoring technology for elderly people to the infamous “nanny cams” — hidden cameras some parents use to spy on their children’s baby sitters. “Big Brother is watching you — there’s something about it that’s very offensive,” she said.

The decision, she said, must ultimately be made by the aging parent. “It has to be negotiated with the parents,” Dr. Schlossberg said. “You want to keep the relationship co-equal. If it’s not an agreement with the parent, it can be a very destructive thing.”

The system Mr. Murdock persuaded his mother to install is called GrandCare, produced by a company of the same name based in West Bend, Wis. It allows families to place movement sensors throughout a house. Information — about when doors were opened, what time a person got into and out of bed, whether there’s been any movement in a room for a certain time period — is sent out via e-mail, text message or voice mail. He said his GrandCare system cost $8,000 to install — about as much as two months at the local assisted-living facility, Mr. Murdock said — plus monthly fees of about $75. The company says that costs vary depending on what features a client chooses.

In addition to giving him peace of mind that his mother is fine, the system helps assuage that midlife sense of guilt. “I have a large amount of guilt,” Mr. Murdock admitted. “I’m really far away. I’m not helping to take care of her, to mow her lawn, to be a good son.”

His mother, Mrs. Roach, was nervous at first when her son brought up the idea of using the system. “I didn’t want to be invaded,” she said. “I didn’t understand the system and was concerned about privacy.” Now that it’s in place, she said, she’s changed her mind: “I was all wrong. I’m not feeling like I’m being watched all day.” And she really enjoys the system’s feature that lets her play games and receive photos and messages from her children and grandchildren. (She never learned to use e-mail.)

Mrs. Roach has no major health issues that require the kind of watching she is getting, and oddly enough, that is the ideal scenario. Elinor Ginzler, senior vice president for livable communities at AARP, said it’s best to discuss using such technology long before a parent’s health has slipped to a point where she might actually need it. “You frame it that way: ‘We’re so happy that things are going so well. We want to make sure to keep it that way. Let’s talk about what we can do to make sure.’ ”

What often follows is pushback. After all, this is not a generation known for its ease with technology.

“My parents’ first reaction to technology is, ’Get it away from me,’ ” said Rachel Meyers, 45, of Brooklyn, whose father, an 80-year-old retired math professor, put at the top of his course syllabus each year: “Do Not E-mail Me.” When her mother, who just turned 84 and lives with her husband in Minneapolis, developed kidney disease, Rachel and her far-flung siblings worried about how to ensure that she was taking the complicated regimen of pills needed daily for her condition.

Their father was not going to be a reliable enforcer. “My father is going to be in his own cave reading a math book with his socks and sandals,” Ms. Meyers laughed. “He is not that guy.”

Through her work as director of community initiatives at the Metropolitan Jewish Health System in Brooklyn, Ms. Meyers learned about a medication management system called MedMinder. It is basically a computerized pillbox. The correct daily dosages of her mother’s 10 different medications are arranged in boxes. When it is time to take them, the pillbox beeps and flashes. If she takes them, Ms. Meyers gets a phone call in Brooklyn saying, essentially, Mom took her pills. Her siblings, including a brother who lives in Australia, get e-mail notifications.

But if her mother doesn’t take the pills within a two-hour window, the system starts nagging. It calls her. It flashes and beeps. Then Ms. Meyers gets a phone call in New York with a message saying her mother missed her dose. “So that’s been interesting,” Ms. Meyers said. “I can call and say, ‘Hey Mom, have you taken your medicine?’ She’ll say, ‘No, I’m on my way.’ I’ll say ‘Do it as a favor for me and take it while we’re on the phone.’ She’ll take it.”

Usually it all works out. But “what does get us into hairy, difficult emotional ground,” Ms. Meyers said, is when her mother’s daily routine changes and her children neglect to reprogram the pillbox to keep up with the shift. For example, as the dialysis began taking a toll, her mother began sleeping later in the morning, but the MedMinder still expected her to take her pills at 7.

“The machine is beeping and she’s not up yet,” Ms. Meyers said. “We get stuck in our own busy lives” and forget to reprogram it. “She says, ’I don’t want it any more.’ Now we’re in a defensive place.”

However, in an interview, Ms. Meyers’s mother, Harriet Meyers, said she had come to appreciate the contraption. “At first I was rebellious. I said, ‘Look, I’m lining up my pills, Rachel.’ I said, ‘I know what I’m doing.’ ” But now she looks at it differently. “I decided to try and now I’m hooked.”

Several academic studies have been undertaken to see just where the line between loving watchfulness and over-intrusion might be drawn. Researchers at Georgia Tech have created an experimental house (called the Aware Home) outfitted with various sensors and motion detectors as well as systems that provide support for medication and memory. They brought in older adults to see how they felt about the devices. “They were quite positive about the idea,” said Ms. Rogers, who is a director of the university’s Human Factors and Aging Laboratory. But the key, she said, is control. The older person is much more amenable if he or she “can control who has access to the information and what information they have access to,” she said.

Other research suggests that having the monitors in place may be enough to give family members peace of mind, and that they are less likely than one might expect to spend time poring over the information. Kelly Caine, a researcher at Indiana University, is just completing a study that found that for all the handwringing over whether to install monitoring technology, the people who received the information from such systems “rarely checked in on the older adults using the monitoring technology more than once per day.” The findings are preliminary, cautioned Ms. Caine, the principal research scientist at the university’s Center for Strategic Health Information Provisioning.

Adult children who call parents to check up on them have learned to be careful about how they phrase their questions. “I personally don’t make it so that I’m watching,” Mr. Murdock said. “I don’t say, ‘Mom, I was looking and you didn’t do this.’ I say, ‘Mom, are you O.K.? I noticed you didn’t take your medicine.’ It’s a balancing act, but it’s an easy conversation. It’s not like I’m calling every day saying, ‘Did you do this or did you do that?’ ”

Other families have also found that the systems reduce the need for nagging conversations. Ray Joss, 91, of Flushing, Queens, has been using a sensor-based system called QuietCare that she found through Selfhelp, a social services company in New York that helps seniors use technology to allow them to live independently. She says that she and her son, who lives in New Jersey, don’t have to dwell on her well-being in conversations because the monitoring system has already let him know how she is. “We talk about other things rather than just how I feel. He doesn’t have to ask me.”

Despite their increasing familiarity with the technology, many elderly people draw the line at cameras.

Susan Oertle has been using a wireless monitoring system called BeClose to check on her aunt, who was recently widowed and had no children of her own. Though the 83-year-old woman recently broke her hip and suffers from a lung condition that compromises her breathing, she is still fiercely independent and likes to stay up till 1:30 a.m. Thanks to wireless sensors in her aunt’s bed, Ms. Oertle can roll over in the middle of the night and notice an e-mail message flashing on her phone reassuring her that her aunt went to sleep. But enough is enough. If there had been cameras to monitor her, Ms. Oertle said, “I think she would have had a bird.”

The demographic projections are startling: In 40 years, the number of Americans past 65 will have doubled.
There’s never been such a graying America.
What’s it like to grow old? How will communities and the nation adapt? A report on how older Americans age, how they grapple with the physical and emotional changes that accompany longer lives, and what lies ahead for us all.

How We Live Now
Welcome to Elderland
Lost and Found
Growing Old in Three Minutes
What We Know About Dementia
Rx for an Aging Nation

I RECENTLY turned 65, just ahead of the millions in the baby boom generation who will begin to cross the same symbolically fraught threshold in the new year to a chorus of well-intended assurances that “age is just a number.” But my family album tells a different story. I am descended from a long line of women who lived into their 90s, and their last years suggest that my generation’s vision of an ageless old age bears about as much resemblance to real old age as our earlier idealization of painless childbirth without drugs did to real labor.

In the album is a snapshot of my mother and me, smiling in front of the Rockefeller Center Christmas tree when she was 75 and I was 50. She did seem ageless just 15 years ago. But now, as she prepares to turn 90 next week, she knows there will be no more holiday adventures in her future. Her mind is as acute as ever, but her body has failed. Chronic pain from a variety of age-related illnesses has turned the smallest errand into an excruciating effort.

On the next page is a photograph of my maternal grandmother and me, taken on a riverbank in 1998, a few months short of her 100th birthday. For one sunny afternoon, I had spirited her away from the nursing home where she spent the last three years of her life, largely confined to a wheelchair, with a bright mind — like my mother’s today — trapped in a body that would no longer do her bidding.

“It’s good to be among the living again,” Gran said, in a tone conveying not self-pity but her own realistic assessment that she had lived too long to live well.

Yet people my age and younger still pretend that old age will yield to what has long been our generational credo — that we can transform ourselves endlessly, even undo reality, if only we live right. “Age-defying” is a modifier that figures prominently in advertisements for everything from vitamins and beauty products to services for the most frail among the “old old,” as demographers classify those over 85. You haven’t experienced cognitive dissonance until you receive a brochure encouraging you to spend thousands of dollars a year for long-term care insurance as you prepare to “defy” old age.

“Deny” is the word the hucksters of longevity should be using. Nearly half of the old old — the fastest-growing segment of the over-65 population — will spend some time in a nursing home before they die, as a result of mental or physical disability.

Members of the “forever young” generation — who, unless a social catastrophe intervenes, will live even longer than their parents — prefer to think about aging as a controllable experience. Researchers who were part of a panel discussion titled “90 Is the New 50,” presented at the World Science Festival in 2008, spoke to a middle-aged, standing-room-only audience about imminent medical miracles. The one voice of caution about inflated expectations was that of Robert Butler, the pioneering gerontologist who was the first head of the National Institute on Aging in the 1970s and is generally credited with coining the term “ageism.”

Earlier this year, a few months before his death from leukemia at age 83, I asked Dr. Butler what he thought of the premise that 90 might become the new 50. “I’m a scientist,” he replied, “and a scientist always hopes for the big breakthrough. The trouble with expecting 90 to become the new 50 is it can stop rational discussion — on a societal as well as individual level — about how to make 90 a better 90. This fantasy is a lot like waiting for Prince Charming, in that it doesn’t distinguish between hope and reasonable expectation.”

The crucial nature of this distinction has become foremost in my thinking about what lies ahead.

My hope is that I will not live as long as my mother and grandmother. We all want to be the exceptions: Elliott Carter, an active composer when he walked onto the stage of Carnegie Hall for his centennial tribute in 2008; Betty White, a bravura comedian who wows audiences at 88; John Paul Stevens, the author of brilliant judicial opinions until the day he retired from the Supreme Court at 90. I, too, hope to go on being productive, writing long after the age when most people retire, in the twilight of the print culture that has nourished my life. Yet it is sobering for me — as it is for Americans in many businesses and professions that once seemed a sure thing — to see younger near contemporaries being downsized out of jobs long before they are emotionally or financially ready for retirement.

Furthermore, I am acutely aware — and this is the difference between hope and expectation — that my plans depend, above all, on whether I am lucky enough to retain a working brain. I haven’t mentioned, because I don’t like to think about it, that my paternal grandmother, who also lived into her 90s, died of Alzheimer’s disease. The risk of dementia, of which Alzheimer’s is the leading cause, doubles every five years after 65.

Contrary to what the baby boom generation prefers to believe, there is almost no scientifically reliable evidence that “living right” — whether that means exercising, eating a nutritious diet or continuing to work hard — significantly delays or prevents Alzheimer’s. This was the undeniable and undefiable conclusion in April of a major scientific review sponsored by the National Institutes of Health.

Good health habits and strenuous intellectual effort are beneficial in themselves, but they will not protect us from a silent, genetically influenced disaster that might already be unfolding in our brains. I do not have the slightest interest in those new brain scans or spinal fluid tests that can identify early-stage Alzheimer’s. What is the point of knowing that you’re doomed if there is no effective treatment or cure? As for imminent medical miracles, the most realistic hope is that any breakthrough will benefit the children or grandchildren of my generation, not me.

I would rather share the fate of my maternal forebears — old old age with an intact mind in a ravaged body — than the fate of my other grandmother. But the cosmos is indifferent to my preferences, and it is chilling to think about becoming helpless in a society that affords only the most minimal support for those who can no longer care for themselves. So I must plan, as best I can, for the unthinkable.

I have no children — a much more common phenomenon among boomers than among old people today. The man who was the love of my adult life died several years ago; now I must find someone else I trust to make medical decisions for me if I cannot make them myself. This is a difficult emotional task, and it does not surprise me, for all of the public debate about end-of-life care in recent years, that only 30 percent of Americans have living wills. Even fewer have actually appointed a legal representative, known as a health care proxy, to make life-and-death decisions.

I can see that the “90 is the new 50” crowd might object to my thinking more about worst-case scenarios than best-case ones. But if the best-case scenario emerges and I become one of those exceptional “ageless” old people so lauded by the media, I won’t have a problem. I can also take it if fate hands me a passionate late-in-life love affair, a financial bonanza or the energy to write more books in the next 25 years than I have in the past 25.

What I expect, though — if I do live as long as the other women in my family — is nothing less than an unremitting struggle, ideally laced with moments of grace. On that day by the riverbank — the last time we saw each other — Gran cast a lingering glance over the water and said, “It’s good to know that the beauty of the world will go on without me.”

If I can say that, in full knowledge of my rapidly approaching extinction, I will consider my life a success — even though I will have failed, as everyone ultimately does, to defy old age.

Susan Jacoby is the author, most recently, of the forthcoming “Never Say Die: The Myth and Marketing of the New Old Age.”

IN our hypercognitive society, fear of forgetfulness has made deep inroads into the psyche. Misplacing car keys, once considered mere absent-mindedness, is now a clinical symptom. Technological ineptitude in the prime of adulthood is ascribed to memory failure.

The mere whiff of perceived memory loss can have terrible consequences in an insecure economy in which midlife workers are regularly (and illegally) laid off on account of their age. This epidemic of anxiety around memory loss is so strong that many older adults seek help for the kind of day-to-day forgetfulness that once was considered normal.

Greater public awareness of Alzheimer’s, far from reducing the ignorance and stigma around the disease, has increased it. People over 55 dread getting Alzheimer’s more than any other disease, according to a 2010 survey by the MetLife Foundation. The fact that only 1 in 8 Americans older than 65 has Alzheimer’s fails to register.

Is the prospect of the disease so horrifying that it should prompt someone to consider suicide? A writer I know whose mother had Alzheimer’s told me she is stockpiling pills. An academic told me he has found someone who will help him die “before I lose my mind.”

Advocacy groups, manufacturers of so-called anti-aging products and the news media have, for varying reasons, tended to inflate the number of sufferers and the horrors of the condition. Doctors, too, have been complicit: some use “cognitive impairment” as an argument for ending dialysis or other life-sustaining treatments.

And some voices in our culture amplify these alarming sentiments. Tony Kushner links Alzheimer’s to suicide in his new Off Broadway play, “The Intelligent Homosexual’s Guide to Capitalism and Socialism With a Key to the Scriptures.”

His 72-year-old hero, Gus Marcantonio, a retired union organizer, tells his assembled family that he has guessed he has Alzheimer’s, and wants to sell the family house and kill himself over the weekend. Gus has no symptoms that the audience can see except once losing his place in a voluble, earnest and moving speech.

In the Korean director Lee Chang-dong’s film “Poetry,” which won the award for best screenplay at Cannes last year, the graceful and empathetic heroine, who is 66, is given a diagnosis of Alzheimer’s. She too has no symptoms other than once forgetting the word for “bus station.” Yet in the film she jumps off a bridge.

The characters have other motives besides fear to end their lives — guilt, mainly. So why is Alzheimer’s brought into these plots so conspicuously? Perhaps because no other motivation seems as plausible to an audience as a reason to kill oneself.

Despite the prevalence of Alzheimer’s in our national conversation, diagnosing the disease is actually difficult. There is no test that can predict whether forgetting names or words like “bus station” is an indicator of the onset of a degenerative disease. Many older people lose the ability to remember proper nouns but then never progress to losing any other part of speech.

Most forgetfulness is not Alzheimer’s, or dementia, or even necessarily a sign of cognitive impairment. And yet any prophecy about impaired cognition — whether it is fulfilled or not — harms people’s sense of self. They begin to be treated like children, patronized with baby talk or avoided. At the assisted living facility where my mother lived until she died last year at age 96, the nursing director told me that some people think Alzheimer’s is contagious. Victims of misdiagnosis — or, just as devastating, self-diagnosis — dread being shunned, rejected by their offspring, going into debt, becoming a “burden,” losing selfhood.

It needn’t be this way. People with cognitive impairments can live happily with their families for a long time. My mother was troubled by her loss of memories, but she discovered an upside to forgetting. She had forgotten old rancors as well as President George W. Bush’s name. We sang together. She recited her favorite poems and surprised me with new material. We had rich and loving times. Suicide didn’t cross her mind.

The mind is capacious. Much mental and emotional ability can survive mere memory loss, as do other qualities that make us human.

In fact, a revolution in care-giving might be slowly taking root, at least among those aware of alternative narratives of memory loss.

Thomas Kitwood, a British psychologist who was a pioneer in the field of dementia care, died in 1998, but his books, which emphasize personhood instead of debilitation, remain influential. “Making an Exit,” a memoir by Elinor Fuchs, a drama professor at Yale, explored the conversational patterns of her mother when she was in an advanced stage of Alzheimer’s. Anne Basting, director of the Center on Age and Community at the University of Wisconsin, Milwaukee, who wrote a play from poems created by people with Alzheimer’s, has a slogan: “Forget Memory. Try Imagination.”

What a difference it would make if everyone began to share these attitudes. We could make cognition-related fear-mongering shameful and rare, make debates about end-of-life care less searing, improve treatment protocols, reaffirm our collective compact with older people, ease our relationships with people of any age who are cognitively impaired, and enable adults to look forward to getting older with hope instead of despair.

Margaret Morganroth Gullette, a scholar at the Women’s Studies Research Center at Brandeis University, is the author of “Agewise: Fighting the New Ageism in America.”

His Highness Prince Aga Khan Ismaili Council for Edmonton has been serving the Ismaili Muslim community in Edmonton and surrounding areas, Red Deer and Fort McMurray for well over a decade. The organization has many parts that work together to assist the community. The Care for Elderly Ismailis Portfolio is the area that works exclusively on assisting the seniors within this community.

Ismaili Muslim seniors can access drop-in centres, and the seniors benefit program which provides information and assistance with applications. The Council works hard to empower seniors, improve their quality of life and keep seniors engaged in their community.

I hope you had the chance to read and reread Dudley Clendinen’s splendid essay, “The Good Short Life,” in The Times’s Sunday Review section. Clendinen is dying of amyotrophic lateral sclerosis, or A.L.S. If he uses all the available medical technology, it will leave him, in a few years’ time, “a conscious but motionless, mute, withered, incontinent mummy of my former self.”

Instead of choosing that long, dehumanizing, expensive course, Clendinen has decided to face death as one of life’s “most absorbing thrills and challenges.” He concludes: “When the music stops — when I can’t tie my bow tie, tell a funny story, walk my dog, talk with Whitney, kiss someone special, or tap out lines like this — I’ll know that Life is over. It’s time to be gone.”

Clendinen’s article is worth reading for the way he defines what life is. Life is not just breathing and existing as a self-enclosed skin bag. It’s doing the activities with others you were put on earth to do.

But it’s also valuable as a backdrop to the current budget mess. This fiscal crisis is about many things, but one of them is our inability to face death — our willingness to spend our nation into bankruptcy to extend life for a few more sickly months.

The fiscal crisis is driven largely by health care costs. We have the illusion that in spending so much on health care we are radically improving the quality of our lives. We have the illusion that through advances in medical research we are in the process of eradicating deadly diseases. We have the barely suppressed hope that someday all this spending and innovation will produce something close to immortality.

But that’s not actually what we are buying. As Daniel Callahan and Sherwin B. Nuland point out in an essay in The New Republic called “The Quagmire,” our health care spending and innovation are not leading us toward a limitless extension of a good life.

Callahan, a co-founder of the Hastings Center, the bioethics research institution, and Nuland, a retired clinical professor of surgery at Yale, point out that more than a generation after Richard Nixon declared the “War on Cancer” in 1971, we remain far from a cure. Despite recent gains, there is no cure on the horizon for heart disease or stroke. A panel at the National Institutes of Health recently concluded that little progress had been made toward finding ways to delay Alzheimer’s disease.

Years ago, people hoped that science could delay the onset of morbidity. We would live longer, healthier lives and then die quickly. This is not happening. Most of us will still suffer from chronic diseases for years near the end of life, and then die slowly.

S. Jay Olshansky, one of the leading experts on aging, argues that life expectancy is now leveling off. “We have arrived at a moment,” Callahan and Nuland conclude, “where we are making little headway in defeating various kinds of diseases. Instead, our main achievements today consist of devising ways to marginally extend the lives of the very sick.”

Others disagree with this pessimistic view of medical progress. But that phrase, “marginally extend the lives of the very sick,” should ring in the ears. Many of our budget problems spring from our quest to do that.

The fiscal implications are all around. A large share of our health care spending is devoted to ill patients in the last phases of life. This sort of spending is growing fast. Americans spent $91 billion caring for Alzheimer’s patients in 2005. By 2015, according to Callahan and Nuland, the cost of Alzheimer’s will rise to $189 billion and by 2050 it is projected to rise to $1 trillion annually — double what Medicare costs right now.

Obviously, we are never going to cut off Alzheimer’s patients and leave them out on a hillside. We are never coercively going to give up on the old and ailing. But it is hard to see us reducing health care inflation seriously unless people and their families are willing to do what Clendinen is doing — confront death and their obligations to the living.

There are many ways to think about the finitude of life. For years, Callahan has been writing about the social solidarity model — in which death is accepted as a normal part of the human condition and caring is emphasized as much as curing.

In the online version of this column let me provide links to three other essays, which offer other perspectives on why we should accept the finitude of life and the naturalness of death. They are: “Born Toward Dying,” by Richard John Neuhaus, “L’Chaim and Its Limits: Why Not Immortality?” by Leon Kass and “Thinking About Aging,” by Gilbert Meilaender.

My only point today is that we think the budget mess is a squabble between partisans in Washington. But in large measure it’s about our inability to face death and our willingness as a nation to spend whatever it takes to push it just slightly over the horizon.

SINCE 1900, the life expectancy of Americans has jumped to just shy of 80 from 47 years. This surge comes mostly from improved hygiene and nutrition, but also from new discoveries and interventions: everything from antibiotics and heart bypass surgery to cancer drugs that target and neutralize the impact of specific genetic mutations.

Now scientists studying the intricacies of DNA and other molecular bio-dynamics may be poised to offer even more dramatic boosts to longevity. This comes not from setting out explicitly to conquer aging, which remains controversial in mainstream science, but from researchers developing new drugs and therapies for such maladies of growing old as heart disease and diabetes.

“Aging is the major risk factor for most diseases,” says Felipe Sierra, director of the Division of Aging Biology at the National Institute on Aging. “The National Institutes of Health fund research into understanding the diseases of aging, not life extension, though this could be a side effect.”

How many years might be added to a life? A few longevity enthusiasts suggest a possible increase of decades. Most others believe in more modest gains. And when will they come? Are we a decade away? Twenty years? Fifty years?

Even without a new high-tech “fix” for aging, the United Nations estimates that life expectancy over the next century will approach 100 years for women in the developed world and over 90 years for women in the developing world. (Men lag behind by three or four years.)

Whatever actually happens, this seems like a good time to ask a very basic question: How long do you want to live?

Over the past three years I have posed this query to nearly 30,000 people at the start of talks and lectures on future trends in bioscience, taking an informal poll as a show of hands. To make it easier to tabulate responses I provided four possible answers: 80 years, currently the average life span in the West; 120 years, close to the maximum anyone has lived; 150 years, which would require a biotech breakthrough; and forever, which rejects the idea that life span has to have any limit at all.

I made it clear that participants should not assume that science will come up with dramatic new anti-aging technologies, though people were free to imagine that breakthroughs might occur — or not.

The results: some 60 percent opted for a life span of 80 years. Another 30 percent chose 120 years, and almost 10 percent chose 150 years. Less than 1 percent embraced the idea that people might avoid death altogether.

These percentages have held up as I’ve spoken to people from many walks of life in libraries and bookstores; teenagers in high schools; physicians in medical centers; and investors and entrepreneurs at business conferences. I’ve popped the question at meetings of futurists and techno-optimists and gotten perhaps a doubling of people who want to live to 150 — less than I would have thought for these groups.

Rarely, however, does anyone want to live forever, although abolishing disease and death from biological causes is a fervent hope for a small scattering of would-be immortals.

In my talks, I go on to describe some highlights of cutting-edge biomedical research that might influence human life span.

For instance, right now drug companies are running clinical trials on new compounds that may have the “side effect” of extending life span. These include a drug at Sirtris, part of GlaxoSmithKline, that is being developed to treat inflammation and other diseases of aging. Called SRT-2104, this compound works on an enzyme called SIRT1 that, when activated, seems to slow aging in mice and other animals. It may do the same thing in humans, though this remains to be proven.

“Many serious attempts are being made to come up with a pill for aging,” said Dr. Sierra, though he suspects that there will not be a single anti-aging pill, if these compounds end up working at all. “It will be a combination of things.”

For over a decade, scientists also have experimented with using stem cells — master cells that can grow into different specialized cells — to replace and repair tissue in the heart, liver and other organs in animals. Some researchers have succeeded in also using them in people. The researchers include the urologist Anthony Atala of Wake Forest Baptist Medical Center, who has grown human bladders and urethras from stem cells that have been successfully transplanted into patients.

But another stem cell pioneer, James Thomson of the University of Wisconsin, believes that stem cell solutions will be a long time coming for more complex organs. “We’re a long way from transplanting cells into a human brain or nervous system,” he said.

ANOTHER intervention that might thwart the impact of aging is bionics: the augmentation or replacement of biological functions with machines. For years cardiac pacemakers have saved and extended the lives of millions of people. More recent devices and machine-tooled solutions have restored hearing to thousands who are deaf and replaced damaged knees and hips. Physicians use brain implants to help control tremors brought on by Parkinson’s disease. Researchers also are working on a wide range of other machine fixes, from exoskeletons that protect joints to experimental devices that tap into the brain activity of paralyzed patients, allowing them to operate computers using thought.

Curiously, after learning about these possibilities, few people wanted to change their votes. Even if I asked them to imagine that a pill had been invented to slow aging down by one-half, allowing a person who is, say, 60 years old to have the body of a 30-year-old, only about 10 percent of audiences switched to favoring a life span of 150 years.

Overwhelmingly the reason given was that people didn’t want to be old and infirm any longer than they had to be, even if a pill allowed them to delay this inevitability.

Others were concerned about a range of issues both personal and societal that might result from extending the life spans of millions of people in a short time. These included everything from boredom and the cost of paying for a longer life to the impact of so many extra people on planetary resources and on the environment. Some worried that millions of healthy centenarians still working and calling the shots in society would leave our grandchildren and great-grandchildren without the jobs and opportunities that have traditionally come about with the passing of generations.

Long-lifers countered that extending healthy lives would delay suffering, possibly for a very long time. This would allow people to accomplish more in life and to try new things. It would also mean that geniuses like Steve Jobs or Albert Einstein might still be alive. Einstein, were he alive today, would be 133 years old.

That’s assuming that he would want to live that long. As he lay dying of an abdominal aortic aneurysm in 1955, he refused surgery, saying: “It is tasteless to prolong life artificially. I have done my share, it is time to go. I will do it elegantly.”

David Ewing Duncan is a contributor to Science Times. This essay is adapted from his most recent e-book, “When I’m 164: The New Science of Radical Life Extension and What Happens If It Succeeds.”

December 13, 2012
Life Expectancy Rises Around the World, Study Finds
By SABRINA TAVERNISE

A sharp decline in deaths from malnutrition and infectious diseases like measles and tuberculosis has caused a shift in global mortality patterns over the past 20 years, according to a report published on Thursday, with far more of the world’s population now living into old age and dying from diseases mostly associated with rich countries, like cancer and heart disease.

The shift reflects improvements in sanitation, medical services and access to food throughout the developing world, as well as the success of broad public health efforts like vaccine programs. The results are striking: infant mortality declined by more than half from 1990 to 2010, and malnutrition, the No. 1 risk factor for death and years of life lost in 1990, has fallen to No. 8.

At the same time, chronic diseases like cancer now account for about two out of every three deaths worldwide, up from just over half in 1990. Eight million people died of cancer in 2010, 38 percent more than in 1990. Diabetes claimed 1.3 million lives in 2010, double the number in 1990.

“The growth of these rich-country diseases, like heart disease, stroke, cancer and diabetes, is in a strange way good news,” said Ezekiel Emanuel, chairman of the department of medical ethics and health policy at the University of Pennsylvania. “It shows that many parts of the globe have largely overcome infectious and communicable diseases as a pervasive threat, and that people on average are living longer.”

In 2010, 43 percent of deaths in the world occurred at age 70 and older, compared with 33 percent of deaths in 1990, the report said. And fewer child deaths have brought up the mean age of death, which in Brazil and Paraguay jumped to 63 in 2010, up from 30 in 1970, the report said. The measure, an average of all deaths in a given year, is different from life expectancy, and is lower when large numbers of children die.

But while developing countries made big strides the United States stagnated. American women registered the smallest gains in life expectancy of all high-income countries’ female populations between 1990 and 2010. American women gained just under two years of life, compared with women in Cyprus, who lived 2.3 years longer and Canadian women who gained 2.4 years. The slow increase caused American women to fall to 36th place in the report’s global ranking of life expectancy, down from 22nd in 1990. Life expectancy for American women was 80.5 in 2010, up from 78.6 in 1990.

“It’s alarming just how little progress there has been for women in the United States,” said Christopher Murray, director of the Institute for Health Metrics and Evaluation, a health research organization financed by the Bill and Melinda Gates Foundation at the University of Washington that coordinated the report. Rising rates of obesity among American women and the legacy of smoking, a habit women formed later than men, are among the factors contributing to the stagnation, he said. American men gained in life expectancy, to 75.9 years from 71.7 in 1990.

Health experts from more than 300 institutions contributed to the report, which provided estimates of disease and mortality for populations in more than 180 countries. It was published in The Lancet, a British medical journal.

The World Health Organization issued a statement on Thursday saying that some of the estimates in the report differed substantially from those done by United Nations agencies, though others were similar. All comprehensive estimates of global mortality rely heavily on statistical modeling because only 34 countries — representing about 15 percent of the world’s population — produce quality cause-of-death data.

Sub-Saharan Africa was an exception to the trend. Infectious diseases, childhood illnesses and maternity-related causes of death still account for about 70 percent of the region’s disease burden, a measure of years of life lost due to premature death and to time lived in less than full health. In contrast, they account for just one-third in South Asia, and less than a fifth in all other regions. Sub-Saharan Africa also lagged in mortality gains, with the average age of death rising by fewer than 10 years from 1970 to 2010, compared with a more than 25-year increase in Latin America, Asia and North Africa.

Globally, AIDS was an exception to the shift of deaths from infectious to noncommunicable diseases. The epidemic is believed to have peaked, but still results in 1.5 million deaths each year.

Over all, the change means people are living longer, but it also raises troubling questions. Behavior affects people’s risks of developing cancer, heart disease and diabetes, and public health experts say it is far harder to get people to change their ways than to administer a vaccine that protects children from an infectious disease like measles.

“Adult mortality is a much harder task for the public health systems in the world,” said Colin Mathers, a senior scientist at the World Health Organization.

Tobacco use is a rising threat, especially in developing countries, and is responsible for almost six million deaths a year globally. Illnesses like diabetes are also spreading fast.

Interesting article about how elders can contribute positively to society, of course provided they are healthy.

"It’s comforting to know that, for many, life gets happier with age. But it’s more useful to know how individuals get better at doing the things they do. The point of culture is to spread that wisdom from old to young; to put that thousand-year-heart in a still young body."

I recently told my 70s-something walking group that I wanted to write about “retrieval disorder,” our shared problem with remembering names and dates, what we had just read and where, even what we had for dinner last night. Or, in my case, the subject of the column I wrote the day before.

One walking buddy suggested I call it delayed retrieval disorder. “It’s not that we can’t remember,” she said. “It just takes us longer, sometimes a lot longer, than it used to.” Then she wondered, “Is it really a disorder? Since it seems to happen to all of us, isn’t this just normal aging?”

Indeed it is, I’ve learned from recent reports, including one released last month by the Institute of Medicine. And it doesn’t mean we’re all headed down the road to dementia, although unchecked, cognitive changes with age can make it increasingly difficult to meet the demands of daily life, like shopping, driving, cooking and socializing.

I am painfully aware of increasingly frequent memory lapses, like where I left my cellphone or glasses. I searched the house the other day for a container of ice cream, only to finally find it in the microwave, where I had planned to soften it. Without a shopping list, I inevitably return from the store without something I really needed. And without a hide-a-key, I would routinely lock myself out of the house.

I was a terrific speller and walking thesaurus most of my life, but now routinely resort to an online dictionary and my computer’s ability to second-guess the word I’m trying to spell.

Although memory issues become more apparent in the Medicare years, gradual changes in cognitive function actually begin decades earlier, their effects usually masked by the brain’s excess of neurons and ability to lay down new connections throughout life.

AARP reassuringly writes in its Staying Sharp booklets, “As brain functions go, forgetting may be almost as important as remembering; it would be inefficient for our brains to try to retain every bit of information we’re exposed to throughout life.”

About a third of healthy older people have difficulty remembering facts, people, places and other things encountered daily, “yet a substantial number of 80-year-olds perform as well as people in their 30s on difficult memory tests,” AARP noted.

Nor are those who do less well cognitively suffering from a brain disease. “Just as you wouldn’t say that a marathon runner who slows down in his 80s has a motor disease, age-related cognitive decline isn’t necessarily pathological,” said Molly V. Wagster, chief of neurosciences at the National Institute on Aging. “We may just be slower to retrieve information, and slower to learn new things.”

Besides, Dr. Wagster told me, “the older brain retains plasticity; it’s capable of making adaptive changes. Certain regions of the brain operate in slightly different ways that may actually be better than at young ages.” Some of the changes, like depth of comprehension and wisdom gleaned through experience, are improvements that can compensate for less positive age-related effects, she said.

Denise C. Park, a psychologist at the University of Texas at Dallas, reports that while the brain’s “processing capacity” declines rather steadily from the 20s onward, “world knowledge,” including vocabulary, increases, at least into the 70s, when it seems to plateau. Still, it is important for people to recognize possibly pathological symptoms of cognitive impairment, like getting lost driving to a familiar place, having difficulty with finances, or failing to take medications correctly — deficits that warrant medical attention, Dr. Wagster said.

As AARP put it, “forgetting where you parked your car can happen to everyone occasionally, but forgetting what your car looks like may be cause for concern.”

Preventing cognitive decline that can interfere with quality of life is a far better option than trying to reverse it. The Institute of Medicine highlighted several actions everyone can take to maximize the chances of remaining cognitively sound well into the twilight years.

First and foremost, “be physically active.” Numerous studies have documented benefits to the brain as well as the body from regular exercise. For example, among 18,766 women ages 70 to 81 participating in the Nurses’ Health Study, those with the highest level of activity had a 20 percent lower risk of cognitive impairment than those who were least active.

Second, prevent or control cardiovascular risk factors, including high blood pressure, smoking, obesity and diabetes. What is good for the heart also appears to be good for the brain. A diet relatively low in fat, cholesterol and sugar and replete in antioxidant-rich vegetables and fish are likely to be protective, as are adequate levels of vitamin D.

Drink alcohol moderately, defined as one drink a day for women, two for men, or not at all. And get adequate sleep — a good seven hours a night — to keep neurons firing at top speed. Depression has a negative effect on cognition at all ages; if you suffer from it, get it treated.

Be well educated. Even if you missed out on a good education early in life, it is not too late to engage in intellectually stimulating activities, including taking courses online or at a local college, reading books, participating in discussion groups, and attending lectures and other cultural activities.

Dr. Park maintains that “cognitive engagement” — learning complex new tasks like quilting, crocheting or digital photography — can improve cognitive performance. But Dr. Wagster emphasized that cognitively stimulating activities should also be personally rewarding or meaningful, not frustrating or just busy work.

“Learning a new language can be very difficult later in life unless one has a compelling reason to do so,” Dr. Wagster said.

Finally, none of these measures may be helpful if they prevent you from being involved socially in leisure or volunteer activities. Social interaction is a strong predictor of healthy aging.

For further reliable information on how to minimize cognitive decline with age, I highly recommend a forthcoming book, “Staying Sharp: 9 Keys for a Youthful Brain Through Modern Science and Ageless Wisdom,” by Henry Emmons and David Alter.

At 10 years old I knew my parents did not wish to be resuscitated nor plugged into machines in the event of serious illness. They told me they were not afraid of death but rather of being kept alive at any cost. I knew they would refuse medical interventions, if they felt there was no purpose except to separate the dying from their deaths. They were wary of doctors who my parents said were trained by a medical culture that had lost touch with what should be its major focus: ending suffering.

My father, Robert N. Butler, was a physician, a psychiatrist and a Pulitzer Prize-winning author who pioneered the field of aging. My mother, Myrna Lewis, had a Ph.D. in social work; her specialty was older women. Together they co-wrote books on aging, mental health, sexuality and public policy. They would have been tickled by the coverage a few months ago of the Iowa state representative Ross Paustian, a Republican, nose-deep in their book “Sex After Sixty” in the middle of a House debate over the collective bargaining rights of teachers.

My parents applied what they learned out in the field to their personal lives. They worked hard to put as much money toward their retirement and old age as they could so that my half-sisters and I would never be financially responsible for them. They told us where we could find copies of their wills and health directives, explaining that these documents clarified their wishes and we would not have to bear the full weight of making end-of-life decisions for them.

As a teenager I hated these discussions. I probably told them to stop torturing me and to stop being so morbid. They were reassuring me about scenarios that I did not want to think about. I could not have known how grateful I would be now.

My parents were prepared, but that is not the same as being ready. Few are ever ready to face the end of life, and often how we imagine living our last days is not the way we do. I was born to older parents: My father was 53, my mother 42.

By the time I was in my early 20s, they were in their late 60s and early 70s.

I began to fear that we would have to pull my father kicking and screaming from his professional life. I knew he would work until the last possible moment because work was his passion. I dreaded the day when physically or mentally he would be stopped from doing what he loved. My mom began to speak about her fear of losing him and the fact that she would have to face her own old age without him at her side. This was around 2003, the summer my mother started walking into walls.

She was angry with herself for her sudden clumsiness. Then one day she lost $400, which she had withdrawn from the bank moments before. On her way home she was almost run over in the street. The driver was so angry he stepped from his car to yell at her.

At home in our living room, little voices drifted through the window from a nearby playground and my mother sat staring at the wall. She seemed upset but said she was just tired. The next morning she phoned me crying from her doctor’s office. She was given a diagnosis of terminal brain cancer and told she might have only three months.

My parents had assumed my father would die first and had prepared for my mother’s widowhood. Now neither of them was able to comprehend or accept her diagnosis. They used a baseball metaphor that my mom came up with. She could run from base to base, she thought, until science had caught up with her disease.

Both of my parents knew from their clinical work the agonizing loss of self that can come with illness. And yet the true insanity of that is something you can never grasp until it is upon you. My mother was unable to do a single thing that truly mattered to her other than survive. She spent the last months of her life trying not so much to live as to get back to a mind that could process its own death. And then she was gone.

My father seemed to age 10 years almost overnight. He knew it. He spoke about what he was doing every day to stay in shape and engaged with life despite his grief. He followed the advice he would have given to his patients. He made sure he exercised. He made sure that he ate. He forced himself to see friends even when he was not up to it. He spoke about the fact that older men who lose their partners have high rates of mortality in the first year. He had clung to work during my mother’s illness, unable to fully face her grief and his own. Now his focus shifted to his daughters and his family. He was changed for the better after losing her. All of his relationships deepened.

To some extent, each of my parents lived out the scenario they had imagined for the other; nevertheless, their preparation had been worth it.

Five years after my mother’s death, my dad died of leukemia. He suffered something called a blast crisis, during which the body attacks its healthy cells, causing agonizing pain. But his doctor followed the plan they had formed together and he died peacefully without extraordinary interventions. He was in comfort and surrounded by his family.

I have a friend who is haunted by the way her parents died. Her family did not know how to discuss or plan for death. They thought any planning would be morbid. They were unfamiliar with palliative care and associated it with giving up hope.

But palliative care, simply stated, is the treatment of the physical and emotional pain that come with illness. It is a system of care that supports both patient and family. And in certain cases it can extend life.

To the small extent that we have any choice in this uncertain life, it is wise to face your own death. In a world where so many of our fellow human beings live with threats of terror and destruction, if you are lucky enough to imagine you might have any measure of control over how you die, that is a privilege that should not go to waste.

Our deaths are the last message we leave for those we love. How my parents died — in comfort — was the way they cared for me after they were gone. I was not ready to lose them in my 20s, but they had prepared and so I was protected.

Their legacy to me was not a given. The illnesses that took them were outcomes that our past selves would have labeled catastrophic, worst-case scenarios. And yet for me these worst-case scenarios, though painful memories, are dwarfed by a much larger story: how my parents lived, how they died and how gracefully they did them both.